Biomedical subjects

William DeFoor

Publications and source records attributed to William DeFoor.

10 recordsLinked to original sources

PubMed2006

Urinary metabolic evaluations in normal and stone forming children.

PURPOSE: Urinary stone disease is relatively rare in children and urinary metabolic evaluations have been the standard in our practice. We have previously reported a high rate of urinary metabolic abnormalities in stone forming children. We compared urinary chemistry values in normal and stone forming children. MATERIAL AND METHODS: A prospective study was performed to assess urinary metabolic profiles in children with no history or a family history of urinary calculi. The 24-hour urine collections were performed and evaluated at an outside central laboratory. Urine chemistry studies were adjusted for creatinine. The data were compared to those on a historical cohort of calcium stone forming children. RESULTS: A total of 58 samples from normal children and 142 from stone forming children were evaluated. Mean age was 10 years in normal children and 12 years in stone forming children. of the normal and stone forming children 45% and 51%, respectively, were female. Supersaturation levels of calcium oxalate as well as calcium to creatinine levels were significantly higher in children with stones. No data confounding by age or sex was identified by stratification. CONCLUSIONS: There are significant differences in urinary metabolic evaluations between normal and stone forming children. This may allow more precise treatment to prevent recurrent stone episodes. We continue to perform metabolic evaluations in all children with documented urolithiasis.

Adolescent↗

PubMed2006

Endoscopic injection of dextranomer/hyaluronic acid copolymer to correct vesicoureteral reflux following failed ureteroneocystostomy.

PURPOSE: The efficacy of endoscopic injection of dextranomer/hyaluronic acid to correct primary vesicoureteral reflux is well documented. We present experience at 2 institutions with endoscopic treatment for vesicoureteral reflux after failed ureteroneocystostomy. MATERIALS AND METHODS: A retrospective review was performed of the records of all patients who underwent endoscopic dextranomer/hyaluronic acid injection to correct vesicoureteral reflux following ureteral reimplantation between April 2002 and July 2005. De novo ipsilateral vesicoureteral reflux was noted after repair of primary nonrefluxing megaureters or renal transplantation and persistent vesicoureteral reflux was noted following attempted vesicoureteral reflux repair. Injection was performed using the standard technique if the ureteral orifice was easily accessible, and percutaneously if access was difficult. RESULTS: Nine male and 9 female patients were identified. Median age was 1.9 years at reimplantation and 6.5 years at injection, and median followup was 19 months. Ten patients underwent extravesical detrusorrhaphy and 8 underwent cross-trigonal reimplantation. Six patients underwent reimplantation for primary megaureter repair and all had resolution of vesicoureteral reflux with injection. Of the 20 renal units 16 (80%) and 15 of 18 patients (83%) had complete resolution of vesicoureteral reflux after 1 injection. One patient had improvement in vesicoureteral reflux and 2 had no improvement. There were no complications resulting from injections. CONCLUSIONS: Endoscopic treatment of vesicoureteral reflux with dextranomer/hyaluronic acid following extravesical or cross-trigonal reimplantation is safe and efficacious, at least at short-term followup. Endoscopic injection should be considered first line treatment for this situation.

Child↗

PubMed2005

The use of perioperative antibiotics in tonsillectomy: does it decrease morbidity?

OBJECTIVE: To assess the efficacy of perioperative antibiotics in decreasing post-operative morbidity among patients undergoing tonsillectomy or adenotonsillectomy. DESIGN: Meta-analysis based on a structured search of the literature, using MEDLINE and the Cochrane database. SUBJECTS: Only articles, which included both treatment and control groups, were included in the final analysis. Studies were limited to ones that involved human subjects, including both children and adults. Studies using steroids and topical antibiotics were excluded. OUTCOMES: Articles were abstracted for patient factors, elements of study design, methods of patient assignment to treatment and control groups, and clinical outcomes. The primary outcome, time required for return to normal oral intake, was analyzed in the final meta-analysis. METHODS: Four hundred and twenty-eight articles were initially identified. There were 23 potentially appropriate articles. Of these, 18 were able to be located in full text form and in English. Seven of these studies directly studied the efficacy of perioperative antibiotics (versus no antibiotics) in decreasing post-operative morbidity. Four studies had sufficient information to calculate effects estimates (xi) and standard deviations (Si) for the primary outcome. Three studies either did not report the outcome of interest or did not report a measure of stability (e.g. p-value or confidence interval). The data available from the first four studies were combined in a quantitative meta-analysis. Statistical analyses were performed using STATA for Windows software. RESULTS: The pooled estimate indicated that the antibiotic group returned to normal oral intake, on average, 1 day sooner than the controls. This difference was found to be statistically significant with a 95% confidence interval of 0.5-1.6 days. An additional assessment of three qualitative reports also suggested the use of perioperative antibiotics for adenotonsillectomy was associated with less post-operative pain. However, studies varied in terms of study quality, sample size, outcome examined, measure used and antibiotic administered. Definitive conclusions regarding the effect of perioperative antibiotics on other outcomes including bleeding, halitosis, fever, activity level and nausea and vomiting could not be drawn due to the small numbers of studies. CONCLUSIONS: In this meta-analysis, the use of perioperative antibiotics in patients who have had tonsillectomy or adenotonsillectomy appears to be associated with a 1-day reduction in the time required for return to normal oral intake. For other potentially important outcomes, such as post operative pain or bleeding, sufficient data were not available to make any definitive conclusions regarding the effect of perioperative antibiotics.

Adolescent↗

PubMed2004

Results of tapered ureteral reimplantation for primary megaureter: extravesical versus intravesical approach.

PURPOSE: Extravesical ureteroneocystostomy is an accepted technique for the surgical treatment of vesicoureteral reflux. However, many surgeons continue to use an intravesical technique when extensive ureteral tailoring is required in the case of primary megaureter. We present our experience and outcomes with these techniques. MATERIALS AND METHODS: A retrospective cohort study was performed of all patients who underwent tapered ureteral reimplantation between 1990 and 2002. Patient demographics, surgical technique and outcomes were recorded. Patients with ureteral dilatation secondary to bladder or urethral pathology were excluded from study. A successful postoperative outcome was defined as improved hydronephrosis and no vesicoureteral reflux. RESULTS: A total of 53 patients with 65 megaureters were identified. Mean patient age at surgery was 4.9 years and mean followup was 3.8 years. Primary obstructive megaureter was present in 31 renal units, while refluxing megaureter was present in 34. An excisional tapering technique was performed in all cases. An extravesical reimplantation was performed in 29 renal units and an intravesical reimplantation in 36. The success rate was 86% for intravesical and 76% for extravesical reimplantation. The success rate was 90% for obstructive megaureters and 74% for refluxing megaureters. Success rate for patients with voiding dysfunction was 93% with an intravesical approach but only 50% with an extravesical approach. CONCLUSIONS: Extensive ureteral tailoring with an extravesical ureteral reimplantation may be performed safely and effectively for primary obstructive megaureter. Patients with voiding dysfunction or preoperative vesicoureteral reflux may benefit from an intravesical ureteral reimplantation.

Adolescent↗

PubMed2004

Bladder calculi after augmentation cystoplasty: risk factors and prevention strategies.

PURPOSE: Lower urinary tract reconstruction is an essential tool in the management of severely dysfunctional bladders in children. The incidence of calculi in augmented bladders has been reported in up to 50% of cases. We analyzed our experience with stone formation in this population to assess risk factors and outcomes. MATERIAL AND METHODS: We performed a retrospective cohort study of all patients who underwent bladder augmentation from 1988 to 2002 at our institution. Patient demographics, risk factors and management were abstracted from the medical record. RESULTS: A total of 105 patients (58 males and 47 females) were identified. Ileum, colon and stomach were used in 37, 18 and 50 patients, respectively. Median age was 8.0 years. Median followup was 8.4 years. A total of 12 patients (11%) were found to have bladder calculi. Ten patients with ileum (27%), 1 with colon (6%) and 1 with stomach (2%) formed stones. All patients had recurrent urinary tract infections. Nine patients were successfully treated with an endoscopic procedure. Four patients (33%) formed recurrent stones despite saline bladder irrigations. One patient had multiple recurrences but is now stone-free on a daily regimen of 20% urea instillation. CONCLUSIONS: Augmentation cystoplasty carries an overall low risk of bladder calculi. Gastrocystoplasty had a significantly lower rate of stone formation than augmentation with ileum and colon. Urinary tract infection is an independent risk factor for stone formation. Endoscopic management is safe and effective in the majority of patients and it may be facilitated by a percutaneous access. Recurrent stones form in some patients despite aggressive medical management.

Child↗

PubMed2003

Risk factors for spontaneous bladder perforation after augmentation cystoplasty.

OBJECTIVES: To present our experience with the use of stomach, ileum, and colon for augmentation cystoplasty to examine the incidence of, and risk factors for, spontaneous perforation. Spontaneous bladder perforation is a potentially life-threatening complication of augmentation cystoplasty with a reported incidence of up to 13%. METHODS: A retrospective review of medical records from 1988 to 2001 identified 107 children (57 males and 50 females) who underwent augmentation cystoplasty at our institution. The etiology for bladder dysfunction included myelomeningocele, VATER (vertebral defects, imperforate anus, tracheoesophageal fistula, radial and renal dysplasia) syndrome, bladder and cloacal exstrophy, posterior urethral valves, and pelvic malignancy. Thirteen patients also had end-stage renal disease. RESULTS: The median follow-up was 7.4 years. Gastrocystoplasty was performed in 50 children (47%), ileocystoplasty in 37 (35%), colocystoplasty in 18 (17%), and gastric-ileal composite neobladder in 2 (2%). Augmentation cystoplasty procedures were performed using a standard technique that included a two-layer anastomosis. Additional procedures at the time of reconstruction included Mitrofanoff neourethra in 66 patients (62%) and bladder neck repair in 44 (41%). Postoperatively, most patients started a strict incremental catheterization regimen. The overall incidence of bladder perforation was 5%, with one traumatic (1%) and four spontaneous (4%) perforations. All patients recovered uneventfully after exploratory laparotomy. CONCLUSIONS: We believe that the relatively low incidence of spontaneous bladder perforation encountered in this series may be explained by the large number of patients with gastrocystoplasty, as well as our strict adherence to a postoperative incremental catheterization program.

Adolescent↗

PubMed2003

Ectopic ureterocele: clinical application of classification based on renal unit jeopardy.

PURPOSE: The Churchill classification system grades the ectopic ureterocele based on the number of renal units in jeopardy. We apply this system to our experience to help predict response to initial surgical intervention. MATERIALS AND METHODS: All cases of ectopic ureterocele diagnosed at our institution between 1990 and 2000 were retrospectively reviewed and categorized using the Churchill classification system. Initial surgical procedure and subsequent outcomes were analyzed. RESULTS: A total of 53 patients were identified, of whom 42% had only upper pole involvement (grade I), 40% ipsilateral upper and lower pole involvement (grade II) and 19% bilateral renal involvement (grade III). Endoscopic incision was definitive in 56% of grade I, 20% of grade II and no grade III ureteroceles. An upper tract approach was definitive in 85% of grade I, 45% of grade II and no grade III ureteroceles. An initial lower tract procedure was successful in 80% of grade II and 100% of grade III ureteroceles. Overall the initial surgical procedure was definitive in 73% of grade I, 48% of grade II and 20% of grade III ureteroceles. CONCLUSIONS: Our results confirm the findings of Churchill. In this series the majority of grade I ureteroceles were successfully managed with an upper tract procedure. However, high grade ureteroceles were more likely to require a secondary operation unless an initial lower tract reconstruction was performed.

Adolescent↗

PubMed2003

Results of single staged hypospadias surgery to repair penoscrotal hypospadias with bifid scrotum or penoscrotal transposition.

PURPOSE: During the last 10 years there has been controversy in the approach to severe hypospadias. Many pediatric urologists have elected to perform a 2-staged procedure to minimize complication rates and improve cosmesis. We continued to perform a single staged repair using the Hodgson XX or Koyanagi technique for even the most severe hypospadias. We review our results during the last 5 years in severe cases of penoscrotal hypospadias with bifid scrotum or penoscrotal transposition. MATERIALS AND METHODS: The medical records of 20 consecutive children presenting to a single surgeon from 1996 to 2000 with severe penoscrotal hypospadias were reviewed. Patients underwent a 1-stage repair using an operative microscope. Cases not requiring further surgery were grouped as successful while cases requiring subsequent procedures were considered as complications. RESULTS: After an average followup of 23 months 16 patients have not required subsequent procedures. Two patients had urethrocutaneous fistulas and 2 had a urethral diverticulum for an overall complication rate of 20%. All 4 patients were successfully treated with 1 additional procedure and have not required further intervention. Another patient with a small urethral diverticulum is being treated conservatively. All patients had satisfactory cosmetic results. CONCLUSIONS: We believe that a single staged repair can be safely and effectively performed even in patients with the most severe penoscrotal hypospadias. The Hodgson XX and Koyanagi repairs are excellent techniques with relatively low complication rates. Pediatric urologists should continue to use these techniques in their armamentarium and strive to perfect a 1-stage approach to severe hypospadias.

Follow-Up Studies↗

PubMed2003

Lower urinary tract reconstruction is safe and effective in children with end stage renal disease.

PURPOSE: Congenital urinary tract anomalies with bladder dysfunction pose a formidable management challenge in children with end stage renal disease (ESRD). We report a series of patients with ESRD who underwent lower urinary tract reconstruction to assess the results and surgical complications. MATERIALS AND METHODS: We retrospectively reviewed the medical records of patients with ESRD who underwent urinary reconstruction. The etiology for renal failure included posterior urethral valves, cloacal anomalies, VATER syndrome and reflux nephropathy. RESULTS: From 1989 to 2000, 20 patients were identified. Median patient age at time of reconstruction was 4.5 years and median followup was 7.3 years. Pre-transplant augmentation cystoplasty was performed in 14 patients (70%) and continent reconstruction without bladder augmentation was performed in 6 patients. Subsequent renal transplant was performed in 19 patients (15 with a living related donor). Overall patient survival was 95%. There was 1 death in the immediate post-transplant period secondary to cerebral edema thought to be due to a precipitous decrease in blood urea nitrogen. The overall graft survival rate is 82%. No patients lost grafts due to infection or technical complications. All patients have stable upper tracts, and mean creatinine is 1.2 mg/dl. Three patients required major surgery due to complications of the reconstruction and 2 treated with gastrocystoplasty had severe hematuria while anuric before transplantation. All patients are continent of urine. CONCLUSIONS: Our long-term data confirm that severe bladder dysfunction can be managed safely and effectively with continent urinary reconstruction in children with ESRD.

Adolescent↗

PubMed2003

Successful renal transplantation in children with posterior urethral valves.

PURPOSE: The treatment of children with posterior urethral valve (PUV) and end-stage renal disease can be challenging. Some series have had poor outcomes after renal transplantation with an increased risk of graft dysfunction and urinary tract infections. We present our experience with a pediatric population and compare it to all the other pediatric renal transplants done at our institution. MATERIALS AND METHODS: We identified 10 patients with PUV who underwent a total of 13 renal transplants between 1990 and 2000. The comparison group included 120 transplants done in 95 patients during the same period. Cumulative allograft survival and function were recorded. RESULTS: Overall patient survival in the PUV group was 100%. Mean age at transplant in the PUV group was 10.0 years and mean followup was 3.9 years. Six patients underwent high proximal urinary tract diversion, while the remainder had primary transurethral valve ablation. Three patients had bladder augmentation before transplantation. Cumulative allograft survival in the PUV group at 1 and 5 years was 85% and 64%, respectively. Of the 10 patients 9 currently have functioning living related donor transplants. One patient lost 3 cadaveric donor transplants to chronic rejection. No patients lost grafts due to infection or bladder dysfunction. Mean serum creatinine of the functioning grafts was 1.1 mg/dl. CONCLUSIONS: Renal transplantation can be performed safely and effectively in patients with PUV, including those who have undergone previous proximal urinary tract diversion. Preoperative bladder management and continued monitoring of bladder and kidney function postoperatively are paramount in the preservation of allograft function.

Child↗